Dr. Little’s Philosophies
The expressive features of the eyes, of course, are of key importance in overall facial rejuvenation; alert, youthful eyes add immeasurably to the rejuvenated quality of a youthful facial shape without jowls.
Volume Replacement Critical
Nowhere in the face is the replacement of lost volume more important than around the eyes…not only to the lower eyelid emptiness (“tear-trough”), but equally to the upper eyelid hollow (“nursing home eyes”). Even in the presence of significant lower-lid fat bags, filling the deficient area below the bags causes most to blend away without their direct removal, leaving the lids fuller and more youthful than would excisional surgery.
The Tide Metaphor
An apt metaphor for such aging around the eyes is the beautiful beach at high tide that becomes less appealing at low tide, when rocks, seaweed, and even trash become exposed at the lower water level (another metaphor first suggested to me by Maryland plastic surgeon John Eng, M.D.). In the human example, of course, our “tide” goes out only once…ever so slowly over our lifetime, as we lose the youthful fullness from around our eyes, exposing our fat bags, our orbital margins or eye sockets, and eventually our cheek bones. Rather than attempting to further reduce or alter these exposed natural structures (which have largely been there all along, but unseen), Dr. Little prefers structural fat grafting to bring back the “tide” and restore the youthful “beach front”…all in a matter of minutes rather than hours. [view: Low Tide Theory of Aging around the Eyes in diagrammatic form]
Conservatism with Other Aspects
When such proper filling is accomplished, removal of upper eyelid skin is almost never required, while removal of lower eyelid skin (through a lower lid scar) becomes necessary in only a minority of Dr. Little’s patients, those with significant descent of their lower-lid muscle complex (orbicularis oculi) and a heavy load of eyelid skin. Dr. Little believes that a change in the shape of the eyes is almost never appropriate, unless the patient presents with an abnormal shape from aging or prior surgery (or has always envied a particular, different shape). While a measured elevation is appropriate to the outer tail of the eyebrow in most patients, elevation of the inner eyebrow usually is not. In fact, when Dr. Little returns fullness to the hollow upper lid, the inner aspect of the eyebrow typically lowers, bringing back an element of youthful brow position almost always evident in the early photographs. Short, full upper and lower eyelids bring back natural, youthful, healthy, alert, and beautiful eyes.
Illustration: detail from Leonardo da Vinci (?), “Portrait of an Unknown Woman (La Belle Ferronière),” ca. 1490-1495, Musée du Louvre, Paris